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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:15:11 PM

Document Has Been Signed on 04/23/2024 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR/
DIRECTOR:		MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 110DATE:
04/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:EXECUTIVE DIRECTOR, MARK PACIATIME VISIT/
INSPECTION COMPLETED:
10:18 AM
NARRATIVE
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On April 23, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced Health and safety visit in conjunction with a case management visit with deficiencies. LPA Mixson met with Marc Pacia, introduced herself and stated the purpose of the visit.

LPA Mixson conducted a tour of the facility, along with the Administrator, and made observations pertaining to the information obtained via unusual incident/injury report (SIR). On April 15, 2024, the Department received an SIR stating a resident received the incorrect medication.

There were no Health and/or Safety violation observed during this visit. LPA Mixson observed the facility utilities operating without issues. Food supply is sufficient. There are no immediate health or safety concerns for residents in care observed currently at the time of this visit.

There are deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22, Division 6, for the SIR dated April 15, 2024, for the incorrect medications to a resident in care, that occurred on April 11, 2024.

An exit interview was conducted, a copy of this report, along with the 809-D and Appeals rights, were provided to the Executive Director, Marc Pacia.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2024 04:15 PM - It Cannot Be Edited


Created By: Venus Mixson On 04/23/2024 at 09:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2024
Section Cited
CCR
80075(b)

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80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee stated that they shall conduct an in-service training for all staff members that assist in administering medication. Licensee stated they will FAX proof of training completion by the POC date to the Department.
Type B
04/29/2024
Section Cited
CCR
80087(a)

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Based on records reviewed, the Licensee did not ensure that medication was properly administered to a resident in care. This poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Venus Mixson
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024


LIC809 (FAS) - (06/04)
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